OPERATIONS Flashcards
SURGICAL ISSUES ABDOMINAL TRAUMA
PRE Assess other injuries - intoxication Cspine stability CT prior to Sugery (OT vsRadiology) Monitoring - IAL Crossmatch (MTP)
INTRA RSI Modified Induction doses Surgery - laparotomy vs laparoscopy - damage control - permissive hypotension Coagulopathy
POST
- ICU/HDU
LIVER TRAUMA
AAST Liver Injury Scale Graded I - V 0 minor lacterations to avulsion from IVC .
Non Operative to Operative
- depends on grading
- Packs around liver 24-48hrs for haemostasis/correction coagulopathy
- Transfer specialist centre
- Consider Interverntional Radiology
High Grade injuries survival <10%
SPLENIC INJURY
CONSERVATIVE (MOST) - IF STABLE
RESECTION PARTIAL / TOTAL - UNSTABLE (RBC, peritonism)
IR Embolisation
Monitor in HDU/ICU
Need penicillin , immunised pneumococcus, H. Influenza
BARIATRIC SURGERY
Morbid Obesity >40 kg m2
Patient Characteristics
- Any age, Genders equal
- T2DM, IHD, Resp Disease, OSA
ISSUES PRE AIRWAY ASSESSMENT IV ACCESS - ultrasound - long cannulas. Assc conditions (T2DM, IHD, OSA)
INTRA Airway type - ETT Preoxygenation!! VENTILATION - ok if head up, IBW TV, PEEP RSI - Aspiration risk Positioning - Nerve Injury NMBD - Monitoring and reversal STAFF SAFETY - Manual handling, bed limits. Maintainence Des vs TIVA Analgesia - short acting , multimodal PONV
POST OP Analgesia - short acting Avoid PPC Risks of respiratory depression - monitoring VTE Prophylaxis
LAPAROSCOPIC COLORECTAL SURGERY
Anaesthesia Issues:
GA + ETT + Muscle Relaxantion
Hypercarbia+Acidosis due to CO2 abs from
pneumoperitoneum, long procedure, compromised ventilation in steep head down - may cause tachyarrthymias, HTN
STEEP HEAD DOWN Several Hours
- Increased VR - increased CO - caution patients with CCF or valvular heart disease
- Airway Migration - endobronchial
- Reduced FRC and TLV = atelectasis
- Increased risk of gas embolism
- Cerebral oedema
- Facial and airway oedema
- Cephalad spread of epidural
Difficult IV access (arms by side) - NIBP (surgeon pressing + long = IAL) - extensions
Conversion to open at any time
Post Op
Neuraxial vs PCA
LIVER RESECTION
- Hepatic Metastases
- Hepato Biliary Tumours ( benign and malignant)
- Trauma
- Organ donation
SURGERY
Initial - Liver mobilisation from peritoneal attachments
- Cholecystectomy
- Expose Vascular anatomy
Resection
- Potential for huge blood loss
- PRINGLE MANOEUVER - clamp hepatoduodenal ligament ( HA, PV, Cystic duct)
-Rarely need to clamp supra and infra hepatic IVC (note they only clamp 90%)
PREOP
Assess - Liver dysfunction, coagulaopathy
CVS/RESP (?will tolerate)
PERIOP
IAL + CVC (CVP)
TECHNIQUE ETT - Controlled Ventilation Thoracic Epidural (risk v benefit) CVP <5cm H20 (CVS Risks) - avoid fluids , vasoconstrictors
COMMUNICATION VITAL
ie. clamping, pneumothorax, blood loss
POST OP
Aim to Extubate
ICU
HERNIA
Protrusion of the whole or part of a viscus from its normal position through an opening in a wall of its containing cavity
ELECTIVE VS EMERGENCY (Acute abdomen)
Patient type - obese, older, pregnancy, chronic cough (COPD, asthma)
Extubation avoid coughing!
OBSTRUCTED OR PERFORATED ABDOMEN
Patient Type:
Any age ; older comorbidities (malignancy)
Systemically unwell with PAIN ++
Major fluid loss into bowel/peritoneal cavity (peritonitis)
Hypovolaemia - developing sepsis
PRE OP Comorbidities -CVS/RESP Hydration, Electrolytes Evidence of SHOCK FBS / Coags / UEC / Crossmatch ABC - MA - resus Look for AKI
URGENT but not emergent - resus prior to induction
Monitoring
IAL , +/- CVC. Temp
Anesthetic GA ETT RSI - probably no epidural ( go for rectus sheath) Large bore IV and IAL Aspirate NGT Fluid Warmers
Post Op
Likely HDU/ICU
Analgesia regional + PCA
Avoid NSAID
OESPHAGECTOMY
Different approaches depending on location of tumour and preference.
IVOR LEWIS =upper midline laparotomy followed by right thoracotomy (middle and lower third oesphagus(
THREE STAGE 0 Upper midline oesphagectomy ,
right thoracotomy and right/left cervical incisions ( tumours of upper and middle third)
PATIENT TYPE
ELderly
High alcohol and tobacco consumption
IHD COPD, may be malnourished
Pre OP STAGING TUMOUR ASSESS CVS'/RESP NURTITIONAL STATUS FBC UEC LFT COAGS LFT and ABG if resp dieasse and OLV
PERIOP
Pre op Nutrition
IAL CVC Temp
Technique:
GA DLT
EPIDURAL
ACTIVE Warming
Multilevel = changing positions
- recheck airway after moving
- long surgery - fluid and blood loss
- manipulation of mediasinal structures = decreased CO and arrthymias
POST OP
ICU
May remain intubated
Analgesia ( difficult - multiple dermatomes)
Physio, VTE. NNutrition
Wait for D3 anastomosis leak
Resp complications , CVS arrthymias, VTE/PE, anastomosis leak, chylothorax, Sepsis
WHIPPLES
SURGERY
OPEN or ROBOTIC
LONG
HEAD UP/ LATERAL - Decreased Preload
Induction:
IAL + CVC + Thoracic Epidural
ETT
Intraoperative Complications
Hypovolaemia - large fluid losses , potential large blood
Hypothermia - active warming
Hyperkalaemia - surgical manipulation lead to PV or HAD obstruction and hepatic ischaemia, intracellular potassium leak
Hypo/Hypreglycaemia - esp if insulinoma (glucose infusion)
Hypoxia - atelectasis
Renal dysfunction - hepatorenal syndrome, monitor urine output.
Post op
THE USUAL + POST OP DIABETES
PHAEOCHROMOCYTOMA
Catecholamine secreting tumour of chromaffin tissue
Usually benign. may be malignant, solitary or multiple.
Most common adrenal but can exist paraganglionic sites base of bladder to base of skull
13% assc with MEN Type 2 - 2A thyroid/parathyroid or 2B Marfan like features with mucosal neuroma
PATIENTS HTN (may be paroxysmal or continuous) Headache Sweating CVS - arrthymias, cardiomyopathy Hyperglycaemia and glycosuria
Dx 24hr meta nephrines. CT/MRI
PREOP
Alpha and Beta blockade (reduces mortality)
Doesnt prevent release but blunts response
phenoxybenzamine 10mg BD - titrated. BP <140. HR <100.
Restore normal circulating volume.
Need 7-10 days of established blockade
Cease phenoxybenzamine the night before
INTRAOP
- CVS - HTN - SNP , Hypo Adrenaline, Norad, Tachy Metoprolol
- Increasing with manipulation, hypotension once resected.
Avoid histamine releasing drugs
POSTOP
ICU
BP - monitor - usually stabilises quickly
Glucoes - hypoglycaemia possible - loss of catecholamines
Steriods - if bilateral adrenalectomy
Analgesia
NEPHRECTOMY
TUMOUR (RCC 90%) -smokers
TRAUMA
OPEN/LAP/ROBOT
PREOP
- associated conditions - anaemia, resp disease, paraneoplastic, HTN Ca
- CVS/RESP
- Renal Injury
- Crossmatch blood
INTRA OP
POSITION - LATERAL , BENT > VQ
BLOOD LOSS
PNEUMOTHORAX - possible
Avoid Nephrotoxics
POST OP
PPC - Analgesia, Physio
PROSTATECTOMY
OPEN VS ROBOT
PREOP
PATIENT FACTORS
- if open epidural
PERIOP
If ROBOT –> access, steep down, long, oedema
POST OP
Ward
TURP
ISSUES
GA VS REGIONAL (Pt, Volume Prostate, Time)
TURP Syndrome (including post op)
Renal Function
Increased morbidity - time >90mins, >45g > 80yo
ANEURYSM
COILING VS CLIPPING WFNS Grade Intubated already IAL - Nimodipine SBP <160mmHg MAP <110, CPP 60-70 Check ECG. Cardiac Function
Careful Induction - Propofol/REMI
CO2 35-40, normal temp, normal glycaemia
POSITIONING
POTENTIAL RUPTURE PLANNING
POST OPERATIVE
AVMs
AVMs congenital abnormalities of the vascular network in which abnomral connections between arteries and veins with intervening capillaries. Direct arterial to venous shunt.
OT vs IR Similar to aneurysm surgery OPEN = Bleeding +++ Avoid BP surges on extubation Post op - microhaemmorhage and diffuse swelling - normal perfusion pressure breakthrough syndrome
ICH
10-15% Strokes
May need OT for
Evacuation of clot (Crainiotomy)
Insertion of EVD
Decompressive Craniectomy
Many already intubated
May have cardaic and other issues - HTN!
Avoid Hyper and Hypotension!! rebleed vs ischaemia
Back to ICU
MRI
Access to Patient Specialised Equipment - Pumps Implanted Devices - PPM Noise levels - hearing protection Emergencies - come out of room Off Floor anaesthesia ECG Changes from MRI - ST Changes
MRI not painful
Airway choice
Temperature management (heat up)
HYDROCEPHALUS - EVD
Obstruction to CSF OUTFLOW (NON-COM)
SOL, SAH, Arnold Chiari
Failure of Absorption of CSF (COMMUNICATING)
SAH, Meningitis , Head injury
Emergency - already intubated
Signs of raised ICP
Fluid Status
Children - blocked shunt
Periop -
IAL for pre exisiting condition
Usually supine, frontal horn lateral ventricle
HYPOTENSION following release of CSF and decrease ICP, Bradycardia also possible
Extubation?
POSTERIOR FOSSA SURGERY
Posterior fodda = pons, cerebellum, medulla, lower cranial nerves, 4th ventricle
Small SPace
PRE OP
Cranial nerve dysfuction - bulbar palsy - aspiration
CVS Status ?PFO, tolerate prone’/sitting
FLUID and electrolytes
Positioning
Supine, prone, lateral, sitting
SITTING = highest risk
CVS instability, decreased CPP, Air embolism, airway obstruction, pneumocephalus
Excessive head flexion -> avoid jugular compression, swelling of tongue and facial and cervical cord oedema -> check for gap between chin and suprasternal notch
VENOUS AIR EMBOLISM - Paradoxical
- brain about heart entrains. via dural vessels/sinus
- greater head up tilt, greater negative intrathoracic pressure, and greater rate air entrained.
3ml/kg - RA to pulm artery, micro bubbles - pulmonary mediators, increase PVR , fall LA and LV filling, loss CO.
Ventricular ectopics are common/ physiological dead space -> V/Q - reduced ETCO2 - increase PaCO2 and decrease PaO2
CVS instability - with retraction
POST OP
HDU/ICU - Small space - deteriorate quickly.
PONV common
SPINAL SURGERY
Trauma, Infection, Malignancy, Congenital, Degenerative
PRONE (Except ACDF)
- Abdomen free
- Head is neutral, level of heart, eyes free
Arms natural position <90 abduction
ISSUES SPINAL MONITORING AIRWAY MANAGENT BLOOD LOSS TEMPERATURE ANALGESIA
Post OP Airway Pain Neuro Obs VTE
CRANIOTOMY
INDICATION
POSITION
PATIENT - GCS , Co morbidities
INDUCTION TIVA, reinforced ETT< temp, Catheter Navigation Pins Lines/Access Communication - concerns, drugs from surgeons
Maintainence PACO2 -35-40 Balanced salt solutions. CPP 60-70 Switch TIVA Osmmotic Therapy
Emergence
Smooth - LMA exchange, remifentanil
Drugs ready for hypertension
Consider if needs extubation
POST OP
NS HDU / HDU
BRONCHOPLEURAL FISTULA
BPF direct communication between tracheobronchial tree and pleural cavity.
Small BPF - malaise, low grade fever, cough, dyspnoea
Large BPF - severe dyspnoea, copious productive cough.
Technique:
Classically - isolate prior to IPPV eg awake / olhaltional intubation. (DANGER)
Newer theory: Sit up, ICC OPEN, Preoxygenate IV Induction, and paralysis Rigid Bronch Insert DLT and isolate lung IPPV via endobronchial portion of tube Lateral for thoracotomy.
LOBECTOMY
INdication - Cancer, Bronchiectasis, TB
PRE OP - Assessment , Risk Strat
Intra OP
Analgesia - TE
Monitoring - IAL + standard
Airway - DLT - OLV
Induction - Propofol/Remi , Maintain Sevo
FLUID - run on drier side, vasoconstrictors
End of case - check integrity of suture line with valsalva
Post op
Chest drains
Extubate
HDU
MEDIASTINAL SURGERY
Either Diagnostic/Therapeutic.
Usually access via suprasternal notch
- Airway obstruction
- Pleura brached (ok as no leak from lung)
- Neck Extension
- Bleeding
PLEURODESIS
introduction of a substance into the pleural space (usually talc) to create inflammatory adhesions.
DLT + OLV
+/- Regional or PCA
No NSAIDs/Dex
PNEUMONECTOMY
Pneumonectomy is excision of a whole lung for lung
cancer. (Mortality 6%)
Big Case IAL + CVC TE DLT OLV Caution Fluid - Vasopressors ICU post NO SUCTION TO DRAIN
Complications Bleeding ALI/Resp Failure Infection AF!
OPEN AAA
PREOP
Identify and evaluate comorbidities
Optimise condition
Make informed decisions for best management
INDUCTION
IAL/CVC/5 lead ECG
TE
-avoid haemodynamic instability @ induction,laryngoscopy, intubation, cross clamp
Use epidural/remi ? volatile - preconidtioning
- epidural - vasodilation
HEPARIN
CROSS CLAMP - ON - AFTERLOAD INCREASE - MYOCARDIAL ISCHAEMIA
CROSS CLAMP OFF = PROFOUND HYPOTENSION - ischaemia
BLOOD LOSS - CELL SALVAGE
COMPLICATIONS SURGICAL - ischaemic limb - embolisation haemorrhage GIT ischaemia (IMA sacrificed) Infections
MEDICAL
Myo Ischaemia
AKI
Resp Failure
EMERGENCY AAA
HIGH MORTALITY CLINICAL JUDGEMENT > RISK INDICES OPEN VS EVAR RESUS - Limit aim SBP 70 MTP/ CEll SALVAGE
PREINDUCTION
IAL (dont delay surgery), CVC (after clmap)
Blood products, rapid infuser
Drugs - pressor + inotrope
INDUCTION
RSI - KEtamine
Anticipate collapse as abdomen opens
Anaesthetic requirement low until cross clamp
HAEMORRHAGE COMMON
CONTROLLED CROSS CLAMP RELEASE - acidosis, potassium
ICU Intubated
EVAR - Elective and Emergency
Occlusion balloon may be deployed in aorta to provide stability.
PERIOP Complications Haemmorhage Ischaemic Limb - embolisation Ischaemic GIT/Spinal Cord Intra abdominal compartment syndrome
MEDICAL MI AKI Resp Failure Coagulopathy
CONTRAST LOAD - AKI CONVERSION TO OPEN REGIONAL/GA HEPARIN HYBRID OT BLEEDING SHEATH PORTS
POST OP
ICU
WATCH AKI
COMPLICATIONS
EVAR - Elective and Emergency
Occlusion balloon may be deployed in aorta to provide stability.
PERIOP Complications Haemmorhage Ischaemic Limb - embolisation Ischaemic GIT/Spinal Cord Intra abdominal compartment syndrome
MEDICAL MI AKI Resp Failure Coagulopathy
CONTRAST LOAD - AKI CONVERSION TO OPEN REGIONAL/GA HEPARIN HYBRID OT BLEEDING SHEATH PORTS
POST OP
ICU
WATCH AKI
COMPLICATIONS
SURGICAL ENDOLEAK MALDEPLOYMENT STENT GRAFT THROMBOSIS/MIGRATION AORTIC RUPTURE DISTAL EMBOLISATION CONVERSION OPEN
MEDICAL AKI; contrast; ischaemia/obstruction MI POst implantation syndrome - fever , CRP, DIC shock, self limiting SEPSIS
CAROTID ENDARTERECTOMY
decreased CBF and intiating platelet or clot embolism
symptomatic - >70% with 2 weeks symptoms
cross clamp - risk of cerebral hypoperfusion and ischaemia (CBF dependant on COW) - a shunt may be placed.
Shunts can kink, damage arterial wall, embolic complications.
BP Targets @ baseline or 20% above
Stimulation = laryngoscopy, cross clamp, sugical stimulus, carotid sinus manipulation. extubation.
GA ADVANTAGES • Provides more controlled operating conditions. • Avoids need for patient compliance. • Reduces CMRO2. • Reduces catecholamine release and stress response of surgery. • Allows greater cardiovascular control/ pharmacological manipulation.
GA DISADVANTAGES
• Reduces CBF.
• May lead to more frequent, unnecessary shunt
use with associated complications.
• Risks failure to detect cerebral ischaemia post–
cross-clamp insertion.
• Haemodynamic fluctuations associated with
induction, laryngoscopy and extubation
LA ADVANTAGES
• Allows direct cerebral function monitoring
• Reduces unnecessary shunt insertion
• Avoids the haemodynamic instability
associated with induction, laryngoscopy,
intubation and extubation
• Preserves cardiovascular and cerebrovascular
autoregulation
LA DISADVANTAGES
• Poor access to airway
• Requires patient compliance
• May be claustrophobic, uncomfortable and
stressful for patient
• May provide inadequate analgesia requiring
supplementation, sedation or general anaesthesia
• Conversion to GA is likely to be hurried and
uncontrolled
COMPLICATIONS
Haemtoma and oedema - re-exploration
Stroke
Nerve damage - hypoglossal > recurrent > superior >margical mandibular nerve
Medical
MI
Labile BP
Post op hypertension may occur possible due to baroreceptor dysfunction .
Marked hypertension may injure myocardium and lead to hyperperfusion symdrome. Hypotension also possible.
HYPERPERFUSION SYndrome = sig increase in CBF following removal of stenosis // headache htn seizures, cerebral oedema SAH ICH - emergency - HTN - ICU
LEG REVASCULARISATION
AND AMPUTATIONS
ELECTIVE VS EMERGECY
Critical Ischaemia within 6 hrs
Start as embolectomy - balloon- stent – bypass
Blood loss - minimal (revas)
Anticoagulaton - Heparin
SURGICAL ongoing ischaemia gangrene to sepsis repeat surgery poor wound healing reperfusion injury - K AKI Compartment syndrome
MEDICAL MI RHABDO AKI REsp Failure
EYE TRAUMA
Open eye with full stomach situation
• Delay before surgery for penetrating eye injury
may increase risk of loss of contents of globe
and increase risk of infection
• Associated trauma, particularly of head and neck
• Danger of extrusion of globe contents at
induction
• Assessment of associated injuries as resuscitation and urgent surgery may be required for non-ophthalmic problems • If surgery is within 24 h of injury, treat as a full stomach • Assess airway for rapid sequence induction • Assess and optimise coexisting medical conditions if time allows
Give alfentanil 0.02 mg/kg, propofol 3 mg/kg, rocuronium 0.6 mg/kg and apply cricoid pressure. Intubation can be performed at 60 seconds without coughing
Antiemetic prophylaxis. • Analgesia with NSAID or opiate. EMERGENCE AND RECOVERY • Antagonism of neuromuscular block • Extubate awake.
TONSILLECTOMY
Pateint - Child vs Adult - OSA, congenital , Malignancy, Smoker, RHF
ETT
Neck Extension
Extubatoin Awake
Post op monitoring
TONSIL BLEED
UPPER AIRWAY OBSTRUCTION
BLOOD LOSS NOT MEASURABLE
ASPIRATION RISK
DOUBLE SUCTION RESUS - CROSSMATCH SMALLER TUBE OROGASTRIC EMPTY STOMACH RSI
TRACHEOSTOMY
ELECTIVE VS EMERGENCY
LA VS GA
Reason - acute/chronic upper airway obs, planned for surgery, aspiration risk
PRE OP - BASELINE / IMAGING / AIRWAY PLANNING
NEED PLANSSSS
COMMUNICATION - tube /retraction/change circuit
SURGEONS SCRUBBED
THYROIDECTOMY
AIRWAY ASSESSMENT
- tracheal deviation narrowing
- mediastinal extension - SVC
CHECK EUTHYROID
CHECK MEDICATIONS
- Carbimazole = inhibits iodination of tyrosyl residues in thyroglobulin
Propylthiouracil = carbimazole + decreases preipheral de iodination of T4->T3
BBlock - control CVS symptoms , propranolol decreases T4-T3 conversion
Iodine - 7-10 days preop - reduction thyroid vascularity
CHECK CARDIAC FUNCTION
MAY BE PART OF MEN SYNDROME
OT
AIRWAY - NIM - muscle relaxants
Cord check at end
POST OP
HYPOCALCAEMIA - check Ca - Parathyroid
RLN Palsy
Haematoma -
RARE COMPLICATIONS
Tracheomalacia
Pneumothorax ( retrosternal resection_
Thyroid Storm - ICU
BURNS
PREOP
Assessment extent
Smoke inhalation
Resuscitation
Theatre Preperation Warm OT Access Multiple Operators Blood Loss / Fluid Catabolic No Sux Analgesia
